Christophe Büla

Risk factors for functional status decline in community-living elderly people: a systematic literature review

To lay the groundwork for devising, improving and implementing strategies to prevent or delay the onset of disability in the elderly, we conducted a systematic literature review of longitudinal studies published between 1985 and 1997 that reported statistical associations between individual base-line risk factors and subsequent functional status in community-living older persons. Functional status decline was defined as disability or physical function limitation. We used MEDLINE, PSYCINFO, SOCA, EMBASE, bibliographies and expert consultation to select the articles, 78 of which met the selection criteria. Risk factors were categorized into 14 domains and coded by two independent abstractors. Based on the methodological quality of the statistical analyses between risk factors and functional outcomes (e.g. control for base-line functional status, control for confounding, attrition rate), the strength of evidence was derived for each risk factor. The association of functional decline with medical findings was also analyzed. The highest strength of evidence for an increased risk in functional status decline was found for (alphabetical order) cognitive impairment, depression, disease burden (comorbidity), increased and decreased body mass index, lower extremity functional limitation, low frequency of social contacts, low level of physical activity, no alcohol use compared to moderate use, poor self-perceived health, smoking and vision impairment. The review revealed that some risk factors (e.g. nutrition, physical environment) have been neglected in past research. This review will help investigators set priorities for future research of the Disablement Process, plan health and social services for elderly persons and develop more cost-effective programs for preventing disability among them.

A Trial of Annual in-Home Comprehensive Geriatric Assessments for Elderly People Living in the Community

BACKGROUND AND METHODSnThe prevention of disability in elderly people poses a challenge for health care and social services. We conducted a three-year, randomized, controlled trial of the effect of annual in-home comprehensive geriatric assessment and follow-up for people living in the community who were 75 years of age or older. The 215 people in the intervention group were seen at home by gerontologic nurse practitioners who, in collaboration with geriatricians, evaluated problems and risk factors for disability, gave specific recommendations, and provided health education. The 199 people in the control group received their regular medical care. The main outcome measures were the prevention of disability, defined as the need for assistance in performing the basic activities of daily living (bathing, dressing, feeding, grooming, transferring from bed to chair, and moving around inside the house) or the instrumental activities of daily living (e.g., cooking, handling finances and medication, housekeeping, and shopping), and the prevention of nursing home admissions.nnnRESULTSnAt three years, 20 people in the intervention group (12 percent of 170 surviving participants) and 32 in the control group (22 percent of 147 surviving participants) required assistance in performing the basic activities of daily living (adjusted odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.8; P = 0.02). The number of persons who were dependent on assistance in performing the instrumental activities of daily living but not the basic activities did not differ significantly between the two groups. Nine people in the intervention group (4 percent) and 20 in the control group (10 percent) were permanently admitted to nursing homes (P = 0.02). Acute care hospital admissions and short-term nursing home admissions did not differ significantly between the two groups. In the second and third years of the study, there were significantly more visits to physicians among the participants in the intervention group than among those in the control group (mean number of visits per month, 1.41 in year 2 and 1.27 in year 3 in the intervention group, as compared with 1.11 and 0.92 visits, respectively, in the control group; P = 0.007 and P = 0.001, respectively). The cost of the intervention for each year of disability-free life gained was about

Effectiveness of Preventive In-Home Geriatric Assessment in Well Functioning, Community-Dwelling Older People: Secondary Analysis of a Randomized Trial

46,000.nnnCONCLUSIONSnA program of in-home comprehensive geriatric assessments can delay the development of disability and reduce permanent nursing home stays among elderly people living at home.

The process of care in preventive in-home comprehensive geriatric assessment.

OBJECTIVES: To determine whether preventive in‐home comprehensive geriatric assessment (CGA) prevents functional decline in community‐dwelling older persons with different baseline functional status: (1) without any basic activities of daily living (BADL) dependency at baseline; and (2) without any instrumental ADL (IADL) and basic ADL dependency at baseline.

Infections and Functional Impairment in Nursing Home Residents: A Reciprocal Relationship

OBJECTIVES: To describe the process of care of a program of in‐home comprehensive geriatric assessment (CGA) and to determine: (1) if there are major findings in all domains of CGA (medical, functional, mental health, and social/ environmental), (2) if there is a continued clinical yield when CGA is repeated annually, and (3) factors that affect patient adherence with recommendations from CGA.

Community physicians' cooperation with a program of in-home comprehensive geriatric assessment

Objectives: To determine the relationship between infections and functional impairment in nursing home residents.

Use of the Cognitive Performance Scale (CPS) to detect cognitive impairment in the acute care setting: Concurrent and predictive validity

OBJECTIVES: To study the cooperation of primary care physicians with a community‐based prevention and health promotion program for older persons, to study physician factors related to cooperation, and to determine any relationship between physician cooperation and patient adherence to program recommendations and patient satisfaction with health care.

The Association between Different Levels of Alcohol Use and Gait under Single and Dual Task in Community-Dwelling Older Persons Aged 65 to 70 Years

The Cognitive Performance Scale (CPS) was initially designed to assess cognition in long term care residents. Subsequently, the CPS has also been used among in-home, post-acute, and acute care populations even though CPS clinimetric performance has not been studied in these settings. This study aimed to determine CPS agreement with the Mini Mental Status Exam (MMSE) and its predictive validity for institutionalization and death in a cohort (N=401) of elderly medical inpatients aged 75 years and over. Medical, physical and mental status were assessed upon admission. The same day, the patients nurse completed the CPS by interview. Follow-up data were gathered from the central billing system (nursing home stay) and proxies (death). Cognitive impairment was present in 92 (23%) patients according to CPS (score >or= 2). Agreement with MMSE was moderate (kappa 0.52, P<.001). Analysis of discordant results suggested that cognitive impairment was overestimated by the CPS in dependent patients with comorbidities and depressive symptoms, and underestimated in older ones. During follow-up, subjects with abnormal CPS had increased risks of death (adjusted hazard ratio (adjHR) 1.7, 95% CI 1.0-2.8, P=.035) and institutionalization (adjHR 2.7, 95% CI 1.3-5.3, P=.006), independent of demographic, health and functional status. Interestingly, subjects with abnormal CPS were at increased risk of death only if they also had abnormal MMSE. The CPS predicted death and institutionalization during follow-up, but correlated moderately well with the MMSE. Combining CPS and MMSE provided additional predictive information, suggesting that domains other than cognition are assessed by professionals when using the CPS in elderly medical inpatients.

Geriatrie: Todeswunsch im Alter: eine Realität. Was wissen wir darüber?

Objectives. This study aimed to describe the cross-sectional and longitudinal association between alcohol intake and gait parameters in older persons. Methods. Community-dwelling persons aged 65–70 years (N = 807). Information on health, functional status, and alcohol use was self-reported at baseline and at 3-year follow-up, whereas gait speed and stride-to-stride variability were measured while walking only (single task) and under dual tasking (counting backwards). Results. Compared to light-to-moderate drinking, heavy drinking was associated with slower gait speed in single task (adj. coeff.: −.040, 95% CI: −.0.78 to −.002, p = .035). No significant association was observed between heavy drinking and gait speed variability. Nondrinkers walked significantly slower than light-to-moderate drinkers in dual task and had significantly higher gait speed variability in both single and dual task, but these associations disappeared after adjustment for comorbidity. At follow-up, 35.2% and 34.1% of the participants walked significantly slower in single and dual task, respectively. This proportion varied a little across drinking categories. Conclusion. At baseline, heavy alcohol consumption was significantly associated with slower gait speed in single task. Selective survival of the fittest heavy drinkers probably explains why this association faded in longitudinal analyses. The trend of poorer gait performance in nondrinkers disappeared after adjustment for comorbidity, suggesting confounding by a worse health status.

Cognitive impairment in elderly medical inpatients: detection and associated six-month outcomes.

Im Medizinstudium lernen wir, dass der Tod so lange wie möglich mit allen uns zur Verfügung stehenden therapeutischen Mitteln bekämpft werden soll. Auch wenn wir dem Tod in der Folge immer wieder begegnen, erscheint er uns oft als etwas eigentlich Unzulässiges und kann als Versagen erlebt werden. So reagieren Ärzte und Pflegende oft ratlos und wissen nicht, was antworten, wenn ein Patient den Wunsch ausdrückt, er «wolle nicht mehr weiterleben». Die Vorstellung, beim Suizid Hilfe leisten zu müssen, ist ein weitverbreitetes Schreckgespenst. Die Betreuenden empfinden dann einen starken Widerspruch zwischen der Respektierung des autonomen Patientenwillens und dem Prinzip, Gutes zu tun. Die Folge ist meist ein unbeholfener Aktivismus, der von den Patienten manchmal als Unverständnis der Medizin gegenüber ihren Wünschen erlebt wird, und es entsteht oft ein Gefühl des Versagens beim Patienten wie den Betreuenden. Der Todeswunsch bleibt ein grosses Tabu in unserer jüdisch-christlich geprägten Gesellschaft, auch wenn diese heute weitgehend säkularisiert ist. Trotzdem beschäftigt die Frage der Endlichkeit unseres Daseins wohl viele unserer (sehr) alten Patienten. Es ist daher wichtig, dass wir uns dieser Realität stellen und sie besser verstehen lernen, wenn wir diese schwierige Frage mit unseren Patienten sinnvoll besprechen und auch auf gesellschaftlicher Ebene ruhig diskutieren wollen.